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1. Bronchoscopy
The thoracic CT scan shows the LUL nodule seen on chest x-ray and several other subcentimeter nodules. The soft tissue window view in F shows lymphadenopathy surrounding the trachea. It is unclear how PET/CT would be useful. The most likely diagnoses would all show increased glucose uptake. Mediastinoscopy could be used to sample the lymph nodes but is invasive and does not sample the lung. The best choice is bronchoscopy with bronchoalveolar lavage, bronchial biopsy and endobronchial ultrasound (EBUS) directed biopsy of the mediastinal masses. The bronchoalveolar lavage is done because of the possibility of infection and bronchial biopsy done for the possibility of a bronchial abnormality as the cause of her cough.
Bronchoscopy did not reveal any masses. However, the LUL bronchi were edematous and thickened. The stains and cultures for pathogens from the bronchoalveolar lavage were negative. EBUS biopsies of the mediastinal lymph nodes were consistent with CLL. The bronchial biopsies are shown in Figure 4.
Figure 4. A: low power view of bronchial biopsy. B: high power view of bronchial biopsy.
Which of the following is the most likely cause of her cough and lung nodules? (Click on the correct answer to proceed to the fifth and final page)